The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate?

Inform the patient that she is counting respirations.

Do not touch the patient until completed.

Obtain without the patient knowing.

Estimate respirations.

Answer and Explanation

The Correct Answer is C

A. Inform the patient that she is counting respirations:
This may lead the patient to alter their breathing pattern, making the result inaccurate.

B. Do not touch the patient until completed:
Touch is not contraindicated, and hand placement on the chest can assist in counting if needed.

C. Obtain without the patient knowing:
This is correct. Most accurate respiratory assessments are done while appearing to check pulse, to prevent voluntary changes in breathing.

D. Estimate respirations:
Estimating is not acceptable and may lead to inaccurate data that affects patient care.

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Correct Answer is D

Explanation

A. Throw the catheter away and begin again:
While starting again is necessary, this choice omits using the first catheter as a landmark, which helps prevent repeated misplacement.

B. Fill the balloon with the recommended sterile water:
The balloon should never be inflated unless urine flow is observed, confirming placement in the bladder.

C. Remove the catheter, wipe with alcohol, and reinsert after lubrication:
Once contaminated, the catheter must not be reused. Alcohol cleaning does not sterilize it.

D. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter:
This is the correct nursing action. It prevents repeated misplacement by using the misplaced catheter as a guide.

A. Flex the knees and keep the feet apart. B. Assume a position far enough away from the client. C. Twist the body in the direction of movement. D. Use the strong back muscles for lifting or moving.

Correct Answer is A

Explanation

A. Flex the knees and keep the feet apart:
This provides a stable base of support and reduces strain on the back when lifting or moving a patient.

B. Assume a position far enough away from the client:
Standing too far away increases the leverage and strain on muscles and makes lifting more dangerous.

C. Twist the body in the direction of movement:
Twisting should be avoided as it can injure the spine. Always pivot or turn with the whole body.

D. Use the strong back muscles for lifting or moving:
The legs, not the back, should do most of the work when lifting to prevent back injuries.

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